NUR 2356 EXAM 3:
MULTIDIMENSIONAL CARE I
FOUNDATIONS QUESTIONS AND
VERIFIED ANSWERS |GRADE A+| JUST
RELEASED
1. A nurse is reviewing the arterial blood gas (ABG) results for a client with chronic
obstructive pulmonary disease (COPD). The results are: pH 7.30, PaCO2 52 mmHg, and HCO3
24 mEq/L. Which acid-base imbalance does the nurse identify?
A. Metabolic acidosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Respiratory alkalosis
Answer: B
Conceptual Explanation: The pH is low (acidosis) and the PaCO2 is high (respiratory),
while the HCO3 is within the normal range, indicating uncompensated respiratory acidosis,
common in clients with COPD due to CO2 retention.
2. A client presents with a serum potassium level of 2.8 mEq/L. Which clinical manifestation
should the nurse prioritize for assessment?
A. Hyperactive bowel sounds
,B. Tall, peaked T waves on EKG
C. Increased muscle tone and tetany
D. Cardiac dysrhythmias and U waves
Answer: D
Conceptual Explanation: Hypokalemia (K+ < 3.5) causes cardiac instability, characterized
by U waves, flattened T waves, and potential life-threatening dysrhythmias. Peaked T
waves are associated with hyperkalemia.
3. A nurse is caring for a client who underwent abdominal surgery 24 hours ago. The client
suddenly reports a ‘popping’ sensation, and the nurse observes the wound has opened with
internal organs protruding. What is the nurse’s immediate action?
A. Push the organs back into the abdominal cavity gently
B. Cover the wound with a dry, sterile dressing
C. Apply a sterile dressing moistened with warm sterile normal saline
D. Position the client in a high-Fowler’s position
Answer: C
Conceptual Explanation: This is an evisceration. The immediate nursing priority is to
cover the exposed organs with sterile, saline-soaked gauze to keep them moist and prevent
necrosis while preparing for emergency surgery.
, 4. When assessing a client for hypocalcemia, the nurse inflates a blood pressure cuff on the
client’s arm and observes carpal spasm. How should the nurse document this finding?
A. Positive Trousseau’s sign
B. Positive Chvostek’s sign
C. Positive Babinski reflex
D. Positive Homans’ sign
Answer: A
Conceptual Explanation: Trousseau’s sign is the induction of carpal spasm by inflating a
blood pressure cuff above systolic pressure for a few minutes, indicating hypocalcemia.
Chvostek’s sign is facial twitching when the facial nerve is tapped.
5. A client with heart failure is receiving furosemide. Which laboratory value is most
important for the nurse to monitor to prevent complications?
A. Serum potassium
B. Serum sodium
C. Serum calcium
D. Serum magnesium
Answer: A
MULTIDIMENSIONAL CARE I
FOUNDATIONS QUESTIONS AND
VERIFIED ANSWERS |GRADE A+| JUST
RELEASED
1. A nurse is reviewing the arterial blood gas (ABG) results for a client with chronic
obstructive pulmonary disease (COPD). The results are: pH 7.30, PaCO2 52 mmHg, and HCO3
24 mEq/L. Which acid-base imbalance does the nurse identify?
A. Metabolic acidosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Respiratory alkalosis
Answer: B
Conceptual Explanation: The pH is low (acidosis) and the PaCO2 is high (respiratory),
while the HCO3 is within the normal range, indicating uncompensated respiratory acidosis,
common in clients with COPD due to CO2 retention.
2. A client presents with a serum potassium level of 2.8 mEq/L. Which clinical manifestation
should the nurse prioritize for assessment?
A. Hyperactive bowel sounds
,B. Tall, peaked T waves on EKG
C. Increased muscle tone and tetany
D. Cardiac dysrhythmias and U waves
Answer: D
Conceptual Explanation: Hypokalemia (K+ < 3.5) causes cardiac instability, characterized
by U waves, flattened T waves, and potential life-threatening dysrhythmias. Peaked T
waves are associated with hyperkalemia.
3. A nurse is caring for a client who underwent abdominal surgery 24 hours ago. The client
suddenly reports a ‘popping’ sensation, and the nurse observes the wound has opened with
internal organs protruding. What is the nurse’s immediate action?
A. Push the organs back into the abdominal cavity gently
B. Cover the wound with a dry, sterile dressing
C. Apply a sterile dressing moistened with warm sterile normal saline
D. Position the client in a high-Fowler’s position
Answer: C
Conceptual Explanation: This is an evisceration. The immediate nursing priority is to
cover the exposed organs with sterile, saline-soaked gauze to keep them moist and prevent
necrosis while preparing for emergency surgery.
, 4. When assessing a client for hypocalcemia, the nurse inflates a blood pressure cuff on the
client’s arm and observes carpal spasm. How should the nurse document this finding?
A. Positive Trousseau’s sign
B. Positive Chvostek’s sign
C. Positive Babinski reflex
D. Positive Homans’ sign
Answer: A
Conceptual Explanation: Trousseau’s sign is the induction of carpal spasm by inflating a
blood pressure cuff above systolic pressure for a few minutes, indicating hypocalcemia.
Chvostek’s sign is facial twitching when the facial nerve is tapped.
5. A client with heart failure is receiving furosemide. Which laboratory value is most
important for the nurse to monitor to prevent complications?
A. Serum potassium
B. Serum sodium
C. Serum calcium
D. Serum magnesium
Answer: A
